Provider Demographics
NPI:1962794396
Name:BRABAW, DAWN LEE (LPN)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:LEE
Last Name:BRABAW
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669
Mailing Address - Country:US
Mailing Address - Phone:315-541-3042
Mailing Address - Fax:
Practice Address - Street 1:6258 US HIGHWAY 11
Practice Address - Street 2:LOT 38
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3926
Practice Address - Country:US
Practice Address - Phone:315-386-3186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290555-1164W00000X
NY674172-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1962794396Medicaid